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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_19_библиотеки_им_акад_М_И_Перельмана
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Essentials of neuromodulation
8. The first superficial injection point will be 1 cm outside of the orbital
rim and in line with the lateral canthus. Based on the assessment needs,
each injection could be 2–4 units of Botox, Jeuveau, or Xeomin or
5–10 units of Dysport.
9. The second injection will be 0.5–1 cm below the first injection point at
the same dosing as above.
10. The third injection will be 0.5–1 cm below the second injection point
and the same dose as above or half the dose depending on the muscle’s
strength or the patients’ aesthetic goals.
11. Repeat injections on the contralateral side.
12. Do not press or rub on the injection sites. If the patient happens to
bleed, apply gentle pressure to stop the bleeding. GENTLE!!! It is
not advised to manipulate the product from the site as adverse events,
and product migration can occur.
Fig. 11.27 Deep extraocular muscles of the eye.
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Results
Within 3–10 days, patients will start to see gradual improvement of the
dynamic wrinkles in the treated area. At no time during the 2 weeks should
more neuromodulator be injected in the same area. It takes a full 2 weeks for
the product to take effect. All good things come to those who wait. At
2 weeks, it is strongly advised that the patient come back in for a followup evaluation. Discuss how the patient feels, how they like their results.
Take after photos in the exact positions as the before photos.
Duration
Neuromodulators last anywhere from 2 to 4 months. The average is about
three. It is essential to inform the clients that they will not be completely
frozen the entire treatment duration. It will take about 2 weeks to become
fully effective, and then at about 6–8 weeks, the neurotoxin will start to
“break.” Break, meaning a little bit of expression or movement will start
to come back, and the patient will notice this. Be sure always to keep photos
for the records so that you have them as a reference point to compare. At
times patients will call at 6 weeks and state that ALL of their neuromodulators wore off, and they need to be re-seen or re-treated. Pictures will come
in handy here as it is likely they see the beginning stages of the reservation
with baby sprouts of the nerve terminals. It is not necessary to wait until all of
the patient’s movement is back. Retreat at 3 months before the full expression is restored; this way, they can train the muscles.
Follow up and special consideration
At the 2 weeks follow up.
It is common for patients to still demonstrate movement in the area treated after treatment. Therefore, it is necessary to assess the patient in animation and add additional units according to the previously treated muscles
with movement. Additional dosing ranges from 4–12 units of Botox, Jeuveau, Xeomin per site, or 10–20 units of Dysport per site.
Persistent crows feet.
If the patient is not appropriately counseled on the use of neuromodulation, they will often come back and say that the treatment did not work
because they have lines still. Educate the patient that the treatment is only
working on the muscles and the motion and that the treatment is not
intended to reduce the static lines. Of course, there is a caveat; in the younger patients, it can reduce the appearance of static lines, but this is not
156 Essentials of neuromodulation
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something the injector should promise. Always teach the client that the
treatment is for the hyperdynamic muscle movement, not the static line
(Table 11.3).
Table 11.3 Complications and management table.
Complications Cause Management
Bruising Puncture of a vessel Arnica ointment
Avoid sun exposure to reduce
the risk of hemosideren
staining
Swelling Trauma Ice
Pain Trauma Ice and acetaminophen
Headache Adverse event from
neuromodulation
Persistant
movement
Static lines Late onset skin care
Diplopia Injection in the extrocular
Impaired
blink reflex
Bunny lines Can become more prominent
Preseptal lines Compensatory mechanism of
Initial dose not adequate or
the muscle is stronger than
anticipated
treatments
Sun exposure
muscles
Rare Time
when the orbicularis oculi
becomes incompetent
the medial preseptal
orbicularis oculi muscle
Acetaminophen and real dark
cocoa
Consider Zinc deficiency
Add additional dose in areas of
movement
If movement is persistent
posterior to the crows feet
treatment zone (this is a
normal finding) meaning
that the Zygomticus major
and minor were preserved
Sun Screen
At home skin care
Skin resurfacing treatments
Inject away from the globe
Treat the nasalis muscle
Reducing the dose of the third
injection point or by adding
a few droplets in the
preseptal space so superficial
you can see the fluid under
the skin. Just like a PPD
plant
Table 11.3 Complications and management table—cont’d
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Complications Cause Management
Infrabrow
lines
The superior lateral
orbicularis oculi muscle
becomes hyper dynamic as
Treat the superior lateral
orbicularis oculi muscle at
the 2 week follow up
a compensatory
mechanism
Photophobia Reduced squinting from over
injections
Lip and cheek
ptosis
Inadvertent injectio n to the
Zygomatic major and
Avoid repeat treatment in this
area
Time
minor
Lagopthalmos High dose and too deep Moistening drops
Ectropian High dose and two deep Moistening drops
Xeropthalmia Previous Lasik surgery Moistening drops
Globe truama Poor injection technique Ocular specialist stat
No effect Consider Zinc deficiency
Report to the medical science
liaison of the maker of the
neuromodulation for
further guidance
Review medical history again,
are they on chelators, are
they zinc deficient, do they
have an underlying disease
not disclosed concerning
possible increased
metabolization
Review the reconstitution,
injections, dosing and
placement
Dysport
allergy
Antihistamine
Follow up with primary care
and Allergist
Notate in chart new allergy
157Neuromodulation injection technique procedural steps
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Details on Dysport allergy
If using Dysport and the patient is allergic, the patient will complain of flu
like symptoms or feeling run down like they are experiencing seasonal allergies or experiencing a sinus infection. Not all patients know that they have a
milk protein allergy, and treatment with Dysport uncovers the allergy. Typically no intervention is needed as it will self-resolve. However, it is appropriate to suggest over the counter antihistamines or see their primary care or
allergist for further testing and lifestyle modifications.
Before and after photos
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Neuromodulation injection technique procedural steps
159
Fig. 11.28 (A) Before photo. (B) After photo.
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Essentials of neuromodulation
Fig. 11.29 (A) Before photo. (B) After photo.
This female patient in her 40s sought treatment of her crow’s feet. Her concern was the lines she sees at rest, along with the loss of a scleral show when she
smiled as seen in Fig. 11.28A. Her treatment goal was to prevent further
breakdown of the skin around the eyes and prevent the extreme closure of
her lids with smiling and squinting. With this treatment, she will have a
brighter, more youthful look in her eyes when she smiled or squinted.
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In Fig. 11.29B it is noted that she has a touch of movement left. An additional 6
units were placed on this side at her follow up. She is a sales representative, so
she spends lots of time in the car with the sun beating on that side of her face.
Treatment
Total dose was 24 units of Botox
Right canthal lines 12 units Botox
Left canthal lines 12 units Botox
Additional treatment at her 2 week follow up was 6 units Botox
Photos 2 weeks apart
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Essentials of neuromodulation
Fig. 11.30 (A) Before photo. (B) After photo.
This young female has porcelain skin with minimal sun damage. She did not
have significant crows feet as evidenced in Fig. 11.30A. Her concern was
with the dynamic rhytids under her eye. As she smiled, the thin skin
bunched up and was bothersome to her. We treated her canthal lines to help
prevent the skin’s bunching directly under her lower lash line. Only 8 units
of Botox were used per side, and it is evident that there was an excellent
softening of the animation in the area. Treatment in this area will help prevent the static rhytids that can become quite troublesome later in her life.
Treatment
Right canthal lines 8
Left canthal lines 8
Photos taken at 2 weeks
Neuromodulation technique in eyebrow lift
Neuromodulation for lateral eyebrow lift
Brows can be asymmetrical and need help to be repositioned on the face.
Low sitting brows (eyebrow ptosis) can convey sadness on the face despite
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the emotion. Dermatochalasis (eyelid skin laxity or Hooding) can make the
patient’s eyes feel heavy and tired. They often have difficulty applying mascara and eyeliner due to the sagging of the tissue into the eyelid area. These
conditions can be helped with proper placement of neuromodulation to the
lateral tail of the superior orbicularis oculi muscle.
Indications for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of eyebrow asymmetry and or eyebrow ptosis.
1. Lateral brow lift
2. Upper eyelid dermatochalasis
3. Lateral eyebrow ptosis
Emotion
Angry
Sad
Tired
Aged
Sinister
Muscles in treatment area
Orbicularis oculi
Frontalis
Levator palpebrae
Muscles to be treated in the targeted zone
Superior lateral orbicularis oculi
Special considerations
The lateral portion of the orbicularis oculi muscle acts as a depressor to the
lateraltail of the eyebrow. The orbicularisoculi directly contribute to the eyes’
closure and more directly creates the crows feet, aka lateral canthal lines. This
muscle acts both in the involuntary reflex of blinking and the voluntary closure of the lids. It is advised that concomitant areas be treated when the request
is to lift the brow. Treating the glabellar complex will elevate the medial brow
and aid in the synergistic effect of the eyebrow ptosis. When injecting this
area, be mindful to keep the injections superficial to not inadvertently inject
the frontalis or the levator palpebrae muscle with deep injections.
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